RHEGMATOGENOUS RETINAL DETACHMENT WITH RETINAL TELANGIECTASIA

JAMES S. KELLEY, M.D., AND P E T E R DANZINGER, M.D. Baltimore, Maryland

A high incidence of retinal detachment is usually reported with Coats' disease.1

In some series detachment varies from local retinal elevation to total retinal sepa­ration. The incidence varies according to the selection of cases and the extent of the detectable detachment. Retinal detach­ment is less common in cases of Leber's multiple miliary aneurysms or cases of retinal telangiectasia. In all categories of these idiopathic, often unilateral exuda­tive vasculopathies, any associated retinal detachment is usually nonrhegmatoge-nous. The patient we describe had retinal vascular telangiectasia with bullous reti­nal detachment. A retinal hole was detect­ed and treated with an encircling scleral buckle. The prompt and permanent reso­lution of subretinal fluid supported our belief that this was a rhegmatogenous retinal detachment. The case is of interest in light of current reports associating rhegmatogenous retinal detachments with other types of retinal vascular disease.2

Retinal telangiectasia may be associated with increased incidence of both exuda­tive and rhegmatogenous retinal detach­ments.

C A S E REPORT

A 34-year-old man was examined here because of a sudden loss of vision in his right eye. He had had a muscle imbalance since childhood. He admitted to a "haze" in the vision of his right eye for many years; however, he was able to read the newspaper with the left eye covered. He denied any history of ocular trauma.

Examination revealed a visual acuity without cor­rection of R.E.: 1/200 (1/200) and L.E.: 6/6 (20/20).

From the Department of Ophthalmology, Greater Baltimore Medical Center, Baltimore, Maryland.

Reprint requests to James S. Kelley, M.D., 14 W. Mount Vernon Place, Baltimore, MD 21201.

An exotropia of 14 prism diopters was present in the right eye. The conjunctiva and the cornea were unremarkable. The anterior chamber was clear, and no cell or flare was evident. The intraocular pressure was 17 mm Hg. Ophthalmoscopic examination of the right eye was impaired because of an extensive vitreous hemorrhage, and only the far periphery at the 3 o'clock position was seen, revealing angioma-tous changes with some retinal exudates. The left eye was normal.

The patient was treated as an outpatient. Homa-tropine 5% drops and bedrest were prescribed. After one week the vitreous hemorrhage in the right eye had cleared so that fluorescein angiography could be performed. On reviewing the angiogram, telangiec-tatic vessels in the midperiphery were documented. On a visit one week later, visual acuity in the right eye had improved to 6/15-(20/50-). The anterior-chamber showed some 3+ cells and 1+ flare. Ophthalmoscopic examination revealed telangiec-tatic vessels, and several angiomatous lesions sur­rounded with some yellow-white exudates involving the superior and inferior nasal quadrant and the inferior temporal quadrant. The patient did not undergo laser photocoagulation because visual acu­ity had dropped to 6/21 (20/70), the intraocular pressure in the right eye was 6 mm Hg with the Goldmann tonometer, and a retinal detachment in­teriorly with a small hole at the 12 o'clock position was present (Fig. 1). The posterior vitreous was detached from the posterior retina but adhered to the operculum.

Results of physical examination were normal. Laboratory test results revealed a complete blood cell count with a hemoglobin of 15.4 g/100 ml, hematocrit of 46.5%, white blood cell count of 14,500 mm 3 with 80% neutrophils, 3% band forms, 14% lymphocytes, and 2% monocytes. Platelet count was normal. The serologic test for syphilis was negative. Coagulation history was negative and anti-nuclear antibodies were negative. Sedimentation rate was 10 mm/hr. Urinalysis was within normal limits. The values of a serologic screen were normal, including the cholesterol of 252 mg/dl and triglyce-rides of 157 mg/dl. The electrocardiogram and chest x-ray were normal.

The patient underwent surgery for repair of the retinal detachment, at which time cryotherapy was applied to the hole at the 1 o'clock position. A high encircling silicone buckle was placed at the equato­rial plane. Cryotherapy was also applied to the telangiectatic vessels in the inferior nasal quadrant. Sclerotomy was not performed because the position of the buckle was satisfactory. Postoperatively, the patient was treated with atropine 1% drops, genta-micin sulfate (Garamycin) drops, and 40 mg of

52 AMERICAN JOURNAL OF OPHTHALMOLOGY 88:52-54, 1979

VOL. 88, NO. 1 RHEGMATOGENOUS RETINAL DETACHMENT 53

Fig. 1 (Kelley and Danzinger). Artist's drawing of retinal detachment before scleral buckle. The hole is near 12 o'clock. There are scattered areas of telan-giectasia and lipid exudate.

prednisone per day. In the following days the total amount of subretinal fluid gradually decreased. The patient was discharged on the seventh postoperative day.

Two weeks after surgery the retina was flat in all quadrants, but visual acuity was only 6/120 (20/400) in the right eye. Best corrected visual acuity in the right eye gradually improved to 6/24 (20/80). Some lipid exudates were seen surrounding the macula. Two months after retinal surgery, the patient re­ceived 120 spots of argon laser photocoagulation to the superior and inferior temporal areas that showed vascular abnormalities. Five months after the sur­gery the visual acuity remained at 6/24- (20/80-), the areas of photocoagulation showed good reaction, and the retina was flat. A persistent leakage of fluorescein dye was noted from the parafoveal ves­sels. Further laser treatment of these vessels was deferred in favor of careful monitoring of the course of the disorder. Visual acuity remained at 6/24 (20/80) 14 months after surgery. No recurrence of the subretinal fluid was noted (Fig. 2).

The areas of telangiectasia inferior nasal treated with cryotherapy had regressed. The inferior tem­poral untreated area, however, also showed less lipid deposits in the retina. Angiography revealed telangiectasia of similar structure in the superior temporal quadrant (Fig. 3).

DISCUSSION

Our case is an example of idiopathic or nonspecific retinal telangiectasia.3 This designation is descriptive and avoids the controversy over classification by epo-

*

Fig. 2 (Kelley and Danzinger). After scleral buckle the retinal detachment resolved. Only one area of telangiectasia near 4 o'clock was treated with cryotherapy. There was little change in the vascular pattern.

nym.4 The findings were unilateral and multifocal in this man. No hereditary, systemic, or central nervous system findings were present to allow a more specific classification.

Retinal detachment of a rhegmatoge-nous type has recently been associated

Fig. 3 (Kelley and Danzinger). Fluorescein angi­ography outlines the abnormal dilated vascular channels temporal to the macula.

54 AMERICAN JOURNAL OF OPHTHALMOLOGY JULY, 1979

with occlusive retinal vascular disease.2 '5

This includes branch retinal vein occlu­sion, central retinal vein occlusion, and central artery occlusion. It has long been associated with advanced diabetic reti-nopathy and sickle cell retinopathy. There are few published reports of rheg­matogenous detachment with retinal tel-angiectasia. Egerer and associates6 found that one of 20 patients they reported had a retinal tear before therapy. The associat­ed detachment responded to a scleral buckling procedure as in our case. The two cases suggest that rhegmatogenous retinal detachments occur with a low but significant incidence in cases with retinal telangiectasia.

Regenbogen and associates2 recently reported a number of factors that contrib­ute to the mechanism of retinal breaks associated with retinal vascular disorders, which include: retinal ischemia, retinal exudation, vitreous detachment, vitreous contraction, growth of retinal neovascu-larization, and perhaps changes in the underlying choroid. In cases with fibro-vascular proliferation and vitreous con­densation, the retinal traction is visible. Where these factors are missing the mech­anism is less obvious. Our patient had a posterior vitreous detachment at a rela­tively early age. It is tempting to assume that this acceleration of a senescent change was caused by the retinal vascular disease and therefore contributed to the retinal detachment. Our patient's rapid response to treatment of the retinal tear minimizes the possibility that the hole is an incidental finding in an otherwise exu­dative detachment.

The primary concern in this case was the extensive rhegmatogenous retinal de­tachment. The associated retinal vascular

disease was treated in a tentative and stepwise manner. Moderate cryotherapy was applied inferior nasal to an area of telangiectasia, but little response was noted. Laser was applied to an area super­ior temporal to the macula. Lipid in the macula seemed slightly reduced. Because the patient was fully active and essential­ly asymptomatic, further treatment was withheld and the patient was followed up. Rhegmatogenous retinal detachment may be a complication of some therapeu­tic modalities suggested for retinal telan­giectasia. The same disorder may be part of the natural course as well.

SUMMARY

A 34-year-old man with unilateral reti­nal telangiectasia developed a bullous retinal detachment. A horseshoe retinal tear was found at 12 o'clock. The detach­ment resolved with placement of an en­circling scleral buckle. The prompt and permanent resolution of subretinal fluid supported our belief that this was a rheg­matogenous retinal detachment.

REFERENCES 1. Spitznas, M., Joussen F., Wessing, A., and

Meyer-Schwickerath, G.: Coats' disease. An epi-demiologic and fluorescein angiographic study. Albrecht von Graefes Arch. Klin. Ophthalmol. 195:241, 1975.

2. Regenbogen, L., Godel, V., Feiler-Ofry, V., Stein, R., and Coscas, G.: Retinal breaks secondary to vascular accidents. Am. J. Ophthalmol. 84:187, 1977.

3. Reese, A. B.: Telangiectasis of the retina and Coats' disease. Am. J. Ophthalmol. 42:1, 1956.

4. Henkind, P., and Morgan, G.: Peripheral reti­nal angioma with exudative retinopathy in adults (Coats' lesion). Br. J. Ophthalmol. 50:2, 1966.

5. Metzler, V., Hohmann, R., and Kaskel, D.: Retinal detachment in cases of occlusion of the central retinal vein or its branches. Klin. Monatsbl. Augenheilkd. 164: 251, 1974.

6. Egerer, I., Tasman, W., and Tomer, T. L.: Coats' disease. Arch. Ophthalmol. 92:109, 1974.